MY LAST DAY IN CLINIC

If you have not read the late Paul Kalanithi's New Yorker article My Last Day as a Surgeon link to it now. Even if you have read it before, do yourself a favor and revisit the text. I'll wait.

Hopefully you returned to this page to come down from a literary high with some inferior patient-physician writing. I am no Paul Kalanithi, who belongs to a hallowed pantheon of doctor-authors that includes Siddhartha Mukherjee, Atul Gawande, and Abraham Verghese. Paul's masterpiece When Breath Becomes Air was only published posthumously through the efforts of his wife Lucy, a fellow Stanford Medicine faculty member who shepherded his manuscript to deserved best-selling fame after he died of metastatic lung cancer.

We should be grateful to the Kalanithis for their grit in producing and sharing a transcendental memoir. One of the most affecting details to a medical oncologist is that Paul continued to write even after cetuximab (a monoclonal antibody infamous for its dermatologic toxicity) ravaged his skin, fissuring his fingertips. Not since blinks of the eye allowed a locked-in author to compose The Diving Bell and the Butterfly has each word on the page required such palpable effort. Proust & Flaubert may have struggled to find le mot juste but never like this.

There are many reasons why When Breath Becomes Air resonates with me, not least of which is that I have personal experience witnessing a book assembled under the most difficult of circumstances. My father's study was right next to my bedroom in my childhood home and, until we owned a reliable word processor, I could hear his typewriter clacking away in the night. This was back in the days when each keystroke was an audible statement of authorial intent (whose erasure needed pungent White-Out, such that every letter was selected & imprinted with care!). After my Dad died in 1994, my mother spent 7 long years bringing Between Cross & Resurrection to press. It is not easy to market a 400+ page book whose author's untimely death rules out any chance of a sequel, and that task is harder still when its subject is a deep theological meditation on the meaning of the seemingly empty day between the Crucifixion and Easter Sunday.

What I share with my father is a love of both The Word and words in general. What I share with Paul Kalanithi is not his eloquence but his sense of calling to the medical profession. During his last day in the operating room, Paul felt a loss, a painful disconnect from what he had trained so arduously to do. With rare exceptions, we the readers cannot know exactly what it is like to abandon a meteoric career in neurosurgery at the height of our powers, but Paul's skillful writing (the man was a master craftsman with both a scalpel and a laptop) makes us feel the emptiness of the lacuna in his professional identity.

Today is my last day in the oncology clinic before I go on medical leave. My work is not as physically demanding as Paul's marathons in the OR, spending hours on end meticulously repairing the broken filaments of the nervous system. The most exertion I have to expend in my clinical role is a sprint to the infusion suite if a patient is having a severe allergic reaction to chemo. But I do so love this job. Siddhartha Mukherjee took some heat for his description of the improvisational oncologist, his critics misinterpreting the phrase to mean that we are always just making it up as we go along. In truth, our choice of treatment regimens is, for the most part, fortified by the most robust, statistically girded evidence, but those under our care don't reliably follow the script; their inalienable right to deviate from our well-laid plans flies in the face of our precious p values and confidence intervals. Any given day is spent toggling between a pre-planned schedule and the unforeseeable reactions to our patients' arising needs, ranging from opioid-strength analgesia to the kind of comfort that can only be delivered through tender words and touch. Oncology is a specialty that demands the entire body of its practitioner, keeping us on our toes while we think and feel our way over and down the peaks and troughs of triumph and tragedy.

But I will not conclude with melodrama. I fully expect to return to duty next month. And when I do, I also anticipate being a better doctor for my absence, for what will be physically taken from me and intangibly given to me. Here's hoping I never look at my patients in quite the same way again.